Tattoo Medical History Consent And Release Form


Please circle YES or NO:
YES NO Diabetes
YES NO Heart Condition
YES NO Faintness or Dizzy Spells
YES NO Epilepsy
YES NO Hemophilia
YES NO Eczema/Psoriasis
YES NO Scarring/Keloiding
YES NO Asthma
YES NO Herpes
YES NO Pregnant/Nursing
YES NO Hepatitis
YES NO Infections
YES NO Blood Thinners
YES NO Prophylactic Antibiotics
Do you have allergies? YES NO If yes, please list:_____________________________________________
Do you take medications? YES NO If yes, please list:__________________________________________
Are you currently under a doctor’s care for a continuing condition? YES NO
Are there any know medical problems that may affect you getting a tattoo? YES NO
When is the last time you ate? _____________________
Please Read:
This is to certify that I am at least 18 years of age.
I am not under the influence of alcohol or drugs.
I understand there is a possibility of an allergic reaction.
I understand there is a possibility of an infection.
I understand that a tattoo is permanent.
I agree to allow for artist interpretation.
I understand that Fine Line Tattoo is not responsible for the interpretation of symbols and foreign languages.
I understand that Fine Line Tattoo does not guarantee any tattoo below the shoe line.
I understand that Fine Line Tattoo does not guarantee any tattoo on the hand or fingers.
I agree to follow all instructions given to me by Fine Line Tattoo and its employees concerning the aftercare of my tattoo.
I understand that there is a chance I might feel lightheaded, dizzy and/or faint due to my decision to receive a tattoo.
*If you feel this way during or after the procedure, please let us know immediately.
I understand there are NO REFUNDS.
I’ve been given a chance to ask questions and they’ve been answered to my satisfaction.
I hereby release Fine Line Tattoo & Body Piercing, LLC and its employees of all responsibility and liability for said tattoo.
Signature _______________________________________Print Name___________________________________
Address ________________________________City, State_____________________ Phone # _______________
D.L. #__________________Today’s Date ________________ D.O.B. ________________ Age _____________
Parent/legal guardian to fill out this section entirely:
If under 18, child AND parent/guardian signatures are to be done in the presence of a notary. Parent/guardian
must be present throughout the procedure and proper I.D. must be shown prior to service.
I, (print name)________________________________________ give permission for my child to receive a tattoo.
Parent/Guardian Signature _____________________________________ D.L. #________________________
Address_________________________________________ City, State ________________________________
Notary’s Statement:
Sworn and Scribed before me on this _______ Day of ______________ 20____.
Notary signature: ______________________________________________ Seal:
-------------------------------------------DO NOT WRITE BELOW THIS LINE-------------------------------------------
Design _______________________________ Placement _______________________ Artist ________________
Touch Up ____ New Tattoo ____ Repair ____ Cover ____ Outline Only ___ Black & Grey ___ Color ___
Care given: Verbally ____ Written ____
Time: Start ______________ Finish ____________


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Parent category: Legal